Anxiety, post-traumatic stress disorder and depression in Korean War veterans 50 years after the war.

Abstract

There has been no comprehensive investigation of psychological health in Australia's Korean War veteran population, and few researchers are investigating the health of coalition Korean War veterans into old age.
To investigate the association between war service, anxiety, post-traumatic stress disorder (PTSD) and depression in Australia's 7525 surviving male Korean War veterans and a community comparison group.
A survey was conducted using a self-report postal questionnaire which included the PTSD Checklist, the Hospital Anxiety and Depression scale and the Combat Exposure Scale.
Post-traumatic stress disorder (OR 6.63, P<0.001), anxiety (OR 5.74, P<0.001) and depression (OR 5.45, P<0.001) were more prevalent in veterans than in the comparison group. These disorders were strongly associated with heavy combat and low rank.
Effective intervention is necessary to reduce the considerable psychological morbidity experienced by Korean War veterans. Attention to risk factors and early intervention will be necessary to prevent similar long-term psychological morbidity in veterans of more recent conflicts.

Full text

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10.1192/bjp.bp.106.025684Access the most recent version at doi:
2007 190: 475-483 The British Journal of Psychiatry

MICHAEL R. MOORE, PAUL JELFS, WARREN K. HARREX and SCOTT HENDERSON
JILLIAN F. IKIN, MALCOLM R. SIM, DEAN P. MCKENZIE, KEITH W. A. HORSLEY, EILEEN J. WILSON,


War veterans 50 years after the war
Anxiety, post-traumatic stress disorder and depression in Korean



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BackgroundBackground
comprehensiveinvestigationofcomprehensiveinvestigationof
psychologicalhealthin Australia’s Koreanpsychologicalhealthin Australia’s Korean
Warveteranpopulation, andfewWarveteranpopulation, andfew
researchersareinvestigatingthehealthofresearchersareinvestigatingthehealthof
coalition KoreanWarveteransinto oldcoalition KoreanWarveteransinto old
age.age.
TherehasbeennoTherehasbeenno
AimsAims Toinvestigatetheassociation Toinvestigatetheassociation
betweenwarservice, anxiety, post-betweenwarservice, anxiety, post-
traumaticstressdisorder (PTSD) and traumaticstressdisorder (PTSD) and
depressionin Australia’s 7525 survivingdepressionin Australia’s 7525 surviving
male KoreanWarveteransandamale KoreanWarveteransanda
communitycomparisongroup.communitycomparisongroup.
Method Method
a self-reportpostalquestionnairewhicha self-reportpostalquestionnairewhich
includedthePTSDChecklist,theHospitalincludedthePTSDChecklist,theHospital
Anxietyand DepressionscaleandtheAnxietyand Depressionscaleandthe
Combat Exposure Scale.Combat Exposure Scale.
AsurveywasconductedusingAsurveywasconductedusing
Results Results
(OR 6.63,(OR 6.63,P P5
P P550.001) anddepression (OR 5.45,0.001) anddepression (OR 5.45,
P P550.001) weremoreprevalentin0.001) weremoreprevalentin
veteransthaninthecomparisongroup.veteransthaninthecomparisongroup.
ThesedisorderswerestronglyassociatedThesedisorderswerestronglyassociated
withheavycombatandlowrank. withheavycombatandlowrank.
Post-traumaticstressdisorderPost-traumaticstressdisorder
50.001), anxiety(OR 5.74,0.001), anxiety (OR 5.74,
ConclusionsConclusions
necessarytoreducetheconsiderablenecessarytoreducetheconsiderable
psychologicalmorbidityexperiencedbypsychologicalmorbidityexperiencedby
KoreanWarveterans.AttentiontoriskKoreanWarveterans.Attentiontorisk
factorsandearlyinterventionwillbefactorsandearlyinterventionwillbe
necessarytopreventsimilarlong-termnecessarytopreventsimilarlong-term
psychologicalmorbidityinveteransofpsychologicalmorbidityinveteransof
morerecentconflicts.morerecentconflicts.
EffectiveinterventionisEffectiveinterventionis
Declaration of interestDeclaration of interest
Fundingdetailedin Acknowledgements.Fundingdetailedin Acknowledgements.
None.None.
The Korean War (1950–1953) is notableThe Korean War (1950–1953) is notable
for several significant battles, the first col-for several significant battles, the first col-
lective military action by United Nationslective military action by United Nations
members, extremes of terrain and weather,members, extremes of terrain and weather,
and a lack of public interest despite a totaland a lack of public interest despite a total
of more than 4 million casualties from bothof more than 4 million casualties from both
sides (Evans, 2000; Odgers, 2003). In thesides (Evans, 2000; Odgers, 2003). In the
postwar decades Korean War veterans havepostwar decades Korean War veterans have
received little attention in veteran health received little attention in veteran health
literature compared with Second Worldliterature compared with Second World
War, Vietnam War and Gulf War veterans, War, Vietnam War and Gulf War veterans,
and few researchers have continued to in-and few researchers have continued to in-
vestigate the health of this ageing groupvestigate the health of this ageing group
into the 1990s and 2000s. These studiesinto the 1990s and 2000s. These studies
generally suggest that adverse health effectsgenerally suggest that adverse health effects
of Korean War service may be persistingof Korean War service may be persisting
well into later life, but their findings arewell into later life, but their findings are
limited by reliance on small, clinic-based limited by reliance on small, clinic-based
samples (Blakesamples (Blake et alet al, 1992; Hyer
1999; McCranie & Hyer, 2000), small num-1999; McCranie & Hyer, 2000), small num-
bers of Korean War veterans within bers of Korean War veterans within larger
study groups (Sutker & Allain, 1996; Portstudy groups (Sutker & Allain, 1996; Port
et al et al, 2001), self-referred populations (Spiro , 2001), self-referred populations (Spiro
et alet al, 1994; Hunt & Robbins, 2001), longitu-, 1994; Hunt & Robbins, 2001), longitu-
dinal studies excluding people withdinal studies excluding people with pre-exist-
ing illnesses (Spiroing illnesses (Spiro et alet al, 1994; Schnurr &
Spiro, 1999) and a focus on non-representa-Spiro, 1999) and a focus on non-representa-
tive prisoners of war (Pagetive prisoners of war (Page et al
EngdahlEngdahl et alet al, 1997; Page & Miller, 2000;, 1997; Page & Miller, 2000;
Port Port et al et al, 2001). Further, few studies have , 2001). Further, few studies have
recruited a non-veteran comparison group recruited a non-veteran comparison group
against which to compare veterans’ results.against which to compare veterans’ results.
This paper describes results from a studyThis paper describes results from a study
that aimed to investigate psychologicalthat aimed to investigate psychological
health in Australia’s entire population of sur-health in Australia’s entire population of sur-
viving male Korean War veterans and a com-viving male Korean War veterans and a com-
parison group of similarly aged Australianparison group of similarly aged Australian
men. The impact of Korean War deployment men. The impact of Korean War deployment
characteristics, such as service branch, agecharacteristics, such as service branch, age
and rank at deployment and combat severity, and rank at deployment and combat severity,
on veterans’ psychological health 50 years on veterans’ psychological health 50 years
after the war was also investigated.after the war was also investigated.
, 1992; Hyer et al et al, ,
larger
pre-exist-
, 1994; Schnurr &
et al, 1991; , 1991;
METHODMETHOD
RecruitmentRecruitment
Our sample was recruited by means of a Our sample was recruited by means of a
postal invitation, with two further mailings postal invitation, with two further mailings
to non-responders. The veterans groupto non-responders. The veterans group
comprised 7612 male Korean War veterans,comprised 7612 male Korean War veterans,
representing all of those considered to be stillrepresenting all of those considered to be still
alive and residing in Australia from the origi-alive and residing in Australia from the origi-
nal deployment of 17 872 Australian armednal deployment of 17 872 Australian armed
forces personnel who served in Korea duringforces personnel who served in Korea during
the conflict and after the armistice, betweenthe conflict and after the armistice, between
June 1950 and April 1956. Vital status andJune 1950 and April 1956. Vital status and
place of residence were determined from ex- place of residence were determined from ex-
tensive searches undertaken for a previoustensive searches undertaken for a previous
mortality study of this group (Harrexmortality study of this group (Harrex et al
2003). Female veterans constituted only2003). Female veterans constituted only
0.3% of the original deployment, and were0.3% of the original deployment, and were
excluded from the study because of their ex-excluded from the study because of their ex-
tremely small numbers and because health tremely small numbers and because health
patterns in men and women can be quite patterns in men and women can be quite
different (Australian Institute of Health and different (Australian Institute of Health and
Welfare, 2002).Welfare, 2002).
We aimed to identify a comparisonWe aimed to identify a comparison
group of men who were of similar age togroup of men who were of similar age to
the Korean War veterans and who were re-the Korean War veterans and who were re-
sident in Australia at the time of the Koreansident in Australia at the time of the Korean
War but did not serve in that conflict. ThisWar but did not serve in that conflict. This
comparison group was defined and identifiedcomparison group was defined and identified
in two stages. First, a general population in two stages. First, a general population
sample of 3022 Australian men aged 65sample of 3022 Australian men aged 65
years and above was randomly selected from years and above was randomly selected from
the Australian electoral roll. Because votingthe Australian electoral roll. Because voting
and electoral roll registration are compulsoryand electoral roll registration are compulsory
in Australia, the electoral roll provides ain Australia, the electoral roll provides a
fairly complete sampling frame of adultfairly complete sampling frame of adult
Australians; exceptions include an esti-Australians; exceptions include an esti-
mated 5% of eligible voters who do notmated 5% of eligible voters who do not
register to vote (Australian Electoral Com-register to vote (Australian Electoral Com-
mission, 2004) and some additional adultsmission, 2004) and some additional adults
excluded on the basis of ineligibility to voteexcluded on the basis of ineligibility to vote
(Australian Electoral Commission, 2005).(Australian Electoral Commission, 2005).
Upon recruitment, the population sampleUpon recruitment, the population sample
participants’ responses to questionnaireparticipants’ responses to questionnaire
items were used to identify a subgroupitems were used to identify a subgroup
who were either born in Australia, or had who were either born in Australia, or had
arrived and settled in Australia by the arrived and settled in Australia by the
end of 1955. This subgroup of populationend of 1955. This subgroup of population
sample participants was included as thesample participants was included as the
study comparison group against whichstudy comparison group against which
the health of the Korean War veteransthe health of the Korean War veterans
was compared.was compared.
et al, ,
Data collectionData collection
Demographic and health information and Demographic and health information and
some Korean War service characteristicssome Korean War service characteristics
were collected by means of a self-reportwere collected by means of a self-report
postal questionnaire. The 14-item Hospitalpostal questionnaire. The 14-item Hospital
Anxiety and Depression (HAD; ZigmondAnxiety and Depression (HAD; Zigmond
& Snaith, 1983) scale was used as a brief& Snaith, 1983) scale was used as a brief
self-rating measure of anxiety and depres-self-rating measure of anxiety and depres-
sion. A review of 747 studies using thission. A review of 747 studies using this
scale suggested that it performed well inscale suggested that it performed well in
assessing symptom severity and casenessassessing symptom severity and caseness
4 754 75
BRITISH JOURNAL OF P SYCHIATRYBRITISH JOURNAL OF P SYCHIATRY ( 2 0 0 7 ), 19 0 , 4 7 5 ^ 4 8 3 . doi : 10 .119 2 / bjp. bp .10 6 . 0 2 5 6 8 4(2 0 0 7 ), 19 0 , 4 7 5 ^ 4 8 3 . doi : 10 .119 2 / bjp . bp.10 6 . 0 2 5 6 8 4
Anxiety, post-traumatic stress disorderAnxiety, post-traumatic stress disorder
and depression in KoreanWar veterans and depression in KoreanWar veterans
50 years after the war50 years after the war
JILLIAN F. IKIN, MALCOLM R. SIM, DEAN P. McKENZIE, JILLIAN F. IKIN, MALCOLM R. SIM, DEAN P. McKENZIE,
KEITH W. A. HORSLEY, EILEEN J. WILSON, MICHAEL R. MOORE, KEITH W. A. HORSLEY, EILEEN J. WILSON, MICHAEL R. MOORE,
PAUL JELFS, WARREN K. HARREX and SCOTT HENDERSON PAUL JELFS, WARREN K. HARREX and SCOTT HENDERSON
AUTHOR’S PROOFAUTHOR’S PROOF

Page 3

IKIN E T ALIKIN E T AL
of anxiety disorders and depression in of anxiety disorders and depression in
somatic, psychiatric and primary care pa-somatic, psychiatric and primary care pa-
tients andin thetientsand inthe
(Bjelland(Bjelland et alet al, 2002). The HAD scale’s, 2002). The HAD scale’s
psychometric propertiespsychometric properties
quite good in terms of factor structure, in-quite good in terms of factor structure, in-
tercorrelation, homogeneity and internaltercorrelation, homogeneity and internal
consistency (Mykletunconsistency (Mykletun et al
equalling 11 or above on the anxiety or equalling 11 or above on the anxiety or
depression sub-scales define cases experien-depression sub-scales define cases experien-
cing clinically significant anxiety or de-cing clinically significant anxiety or de-
pression respectively (Zigmond & Snaith,pression respectively (Zigmond & Snaith,
1983).1983).
Post-traumatic stress disorder (PTSD) Post-traumatic stress disorder (PTSD)
was measured using the 17-item Posttrau-was measured using the 17-item Posttrau-
matic Stress Disorder Checklist (Blanchardmatic Stress Disorder Checklist (Blanchard
et alet al, 1996; Cook, 1996; Cook et al et al, 2005). The Check-
list has been shown to have high internal list has been shown to have high internal
consistency (Cookconsistency (Cook et alet al, 2005), and to
correlate well with other measures of PTSD correlate well with other measures of PTSD
such as the Clinician Administered PTSDsuch as the Clinician Administered PTSD
Scale (BlanchardScale (Blanchard et alet al, 1996). Three ver-
sions of the PTSD Checklist are available,sions of the PTSD Checklist are available,
although the differences between them arealthough the differences between them are
minor. Our study used the PTSD Checklist minor. Our study used the PTSD Checklist
– S, which is a non-military version that can – S, which is a non-military version that can
be referenced to any specific traumaticbe referenced to any specific traumatic
event; questions refer to ‘the stressful ex- event; questions refer to ‘the stressful ex-
perience’. Total scores range from 17 to perience’. Total scores range from 17 to
85. In Australian Vietnam War combat ve-85. In Australian Vietnam War combat ve-
terans cut-off scores of 45 or 50 on theterans cut-off scores of 45 or 50 on the
PTSD Checklist have both been shown toPTSD Checklist have both been shown to
have good diagnostic accuracy in relation have good diagnostic accuracy in relation
to DSM–IV PTSD diagnoses (Forbes to DSM–IV PTSD diagnoses (Forbes et al
2001).2001).
The seven-item Combat Exposure Scale The seven-item Combat Exposure Scale
(CES; Keane (CES; Keane et alet al, 1989) was used to, 1989) was used to
measure the severity of combat experience measure the severity of combat experience
during the Korean War deployment. The during the Korean War deployment. The
CES is a widely used measure of combat CES is a widely used measure of combat
exposure in war veterans (Blakeexposure in war veterans (Blake et al
1992; Engdahl1992; Engdahl et alet al, 1997; Hyer
1999; McCranie & Hyer, 2000). Final1999; McCranie & Hyer, 2000). Final
scores on the CES are divided into sixscores on the CES are divided into six
categories of combat severity, ranging fromcategories of combat severity, ranging from
‘no combat’ to ‘heavy combat’ (Keane‘no combat’ to ‘heavy combat’ (Keane et al
1989; Spiro1989; Spiro et al et al, 1994)., 1994).
Information regarding the year that ve- Information regarding the year that ve-
terans first joined the Australian armed terans first joined the Australian armed
forces, any deployment to other major mili- forces, any deployment to other major mili-
tary conflicts, and whether or not they were tary conflicts, and whether or not they were
wounded in action during the Korean War wounded in action during the Korean War
deployment and any associated treatment deployment and any associated treatment
or evacuation, was also collected in the or evacuation, was also collected in the
self-report postal questionnaire. Data on self-report postal questionnaire. Data on
additional KoreanWarservice characteristics additionalKorean War servicecharacteristics
such as Navy, Army or Air Force service,such as Navy, Army or Air Force service,
rank, age at deployment, and date and dura-rank, age at deployment, and date and dura-
tion of deployment, were obtained fromtion of deployment, were obtained from
Department of Veterans’ Affairs’ records. Department of Veterans’ Affairs’ records.
general general population population
areare consideredconsidered
et al, 2001). Scores, 2001). Scores
, 2005). The Check-
, 2005), and to
, 1996). Three ver-
et al, ,
et al, ,
et al, ,, 1997; Hyer et al
et al, ,
Statistical analysis Statistical analysis
Statistical analyses and data transforma- Statistical analyses and data transforma-
tions were predominantly performed using tions were predominantly performed using
theStatistical Package theStatisticalPackage
Sciences version 11.5 software packageSciences version 11.5 software package
with some specified analyses performed with some specified analyses performed
using Stata version 8.0 for Windows.using Stata version 8.0 for Windows.
It was anticipated that the age distribu-It was anticipated that the age distribu-
tion of the comparison group drawn fromtion of the comparison group drawn from
the electoral roll (26% agedthe electoral roll (26% aged 5
52% aged 70–79 years and 22% aged 52% aged 70–79 years and 22% aged
5580 years) would differ notably from that 80 years) would differ notably from that
of the Korean War veteran population (8% of the Korean War veteran population (8%
agedaged 5570 years, 83% aged 70–79 years 70 years, 83% aged 70–79 years
and 9% agedand 9% aged 5580 years). Weighting fac- 80 years). Weighting fac-
tors based on the proportions of partici-tors based on the proportions of partici-
pants in 5-year age bands in each grouppants in 5-year age bands in each group
were therefore applied to the results of the were therefore applied to the results of the
comparison group participants to correctcomparison group participants to correct
for the difference in age distribution be-for the difference in age distribution be-
tween this group and the participating tween this group and the participating
Korean War veterans. Korean War veterans.
Group results on dichotomous healthGroup results on dichotomous health
outcomes (e.g. PTSD Checklist casesoutcomes (e.g. PTSD Checklist cases v. v.
non-cases) were first presented as preva- non-cases) were first presented as preva-
lence percentages after applying the agelence percentages after applying the age
weighting factors to the results of the weighting factors to the results of the
comparison group participants. Group dif-comparison group participants. Group dif-
ferences were first quantified using non-ferences were first quantified using non-
weighted but age-adjusted prevalence odds weighted but age-adjusted prevalence odds
ratios and then estimated after accounting ratios and then estimated after accounting
for additional potential confounding fac-for additional potential confounding fac-
tors as well as current age. Odds ratiostors as well as current age. Odds ratios
and their 95% confidence intervals (Altmanand their 95% confidence intervals (Altman
et alet al, 2000) and level of significance were , 2000) and level of significance were
obtained obtained using binary logistic regression using binary logistic regression
(Hosmer & Lemeshow, 2000). Continuous(Hosmer & Lemeshow, 2000). Continuous
outcomes (e.g. PTSD Checklist score) wereoutcomes (e.g. PTSD Checklist score) were
initially compared between groups usinginitially compared between groups using
mean and standard deviation scores aftermean and standard deviation scores after
applying the weighting factor to the resultsapplying the weighting factor to the results
of the comparison group participants. Differ- of the comparison group participants. Differ-
ences between unweighted means were thenences between unweighted means were then
analysed using multiple linear regressionanalysed using multiple linear regression
(Montgomery (Montgomery et alet al, 2001) with Stata version, 2001) with Stata version
8.0, first adjusting for current age and subse-8.0, first adjusting for current age and subse-
quently adjusting for additional potentialquently adjusting for additional potential
confounding factors as well as current age.confounding factors as well as current age.
Differences across subgroups of Korean Differences across subgroups of Korean
War veterans according to deployment War veterans according to deployment
characteristics were modelled using binarycharacteristics were modelled using binary
logistic regression. Odds ratios and their logistic regression. Odds ratios and their
95% CIs and level of significance were first95% CIs and level of significance were first
obtained using raw outcome counts, andobtained using raw outcome counts, and
then calculated with adjustment for potential then calculated with adjustment for potential
confounding factors. For some deploymentconfounding factors. For some deployment
characteristics (exposures) the existence andcharacteristics (exposures) the existence and
magnitude of response trends in outcomemagnitude of response trends in outcome
prevalence across exposure categories were prevalence across exposure categories were
for forthe theSocial Social
570 years, 70 years,
also computed, using the exposure categoriesalso computed, using the exposure categories
as linear variables in the regressions. as linear variables in the regressions.
RESULTS RESULTS
From the study population of 7612 KoreanFrom the study population of 7612 Korean
War veterans, 100 were removed from theWar veterans, 100 were removed from the
sample because they were reported to besample because they were reported to be
dead ( dead (n n¼95), residing overseas (
to have never been deployed to Koreato have never been deployed to Korea
( (n n¼4). An additional 13 Korean War veter-
ans were identified and added to the study ans were identified and added to the study
group, bringing the final study group total group, bringing the final study group total
to 7525. Of these, 6122 (81.4%) veterans to 7525. Of these, 6122 (81.4%) veterans
participated in the study by returning aparticipated in the study by returning a
completed questionnaire. From the elector- completed questionnaire. From the elector-
al roll sample of 3022 men, 58 were re- al roll sample of 3022 men, 58 were re-
moved because they were reported to be moved because they were reported to be
dead (dead (n n¼43), residing overseas (
Korean War veterans (Korean War veterans (n n¼2, who were sub-
sequently included in the veteran group) or sequently included in the veteran group) or
ineligibleforparticipation ineligiblefor participation
example too young or female). The final example too young or female). The final
population sample totalled 2964 men, ofpopulation sample totalled 2964 men, of
whom 1893 (63.9%) participated. A reviewwhom 1893 (63.9%) participated. A review
of questionnaire responses provided by theof questionnaire responses provided by the
1893 population sample participants iden-1893 population sample participants iden-
tified an eligible comparison group oftified an eligible comparison group of
1510 (80%) men who were Australian-1510 (80%) men who were Australian-
born or residing in Australia at the timeborn or residing in Australia at the time
of the Korean War. It is the results for these of the Korean War. It is the results for these
1510 comparison group participants that1510 comparison group participants that
are compared with those of the Korean are compared with those of the Korean
War veteran participants in this study. War veteran participants in this study.
95), residing overseas (n n¼1) or1) or
4). An additional 13 Korean War veter-
43), residing overseas (n n¼1),
2, who were sub-
1),
((n n¼12;for for12;
Demographic characteristicsDemographic characteristics
As anticipated, the Korean War veteransAs anticipated, the Korean War veterans
group had a smaller proportion of partici-group had a smaller proportion of partici-
pants under the age of 70 years and overpants under the age of 70 years and over
the age of 80 years than the comparisonthe age of 80 years than the comparison
group. Half of the veterans group weregroup. Half of the veterans group were
aged 70–74 years. The mean age in bothaged 70–74 years. The mean age in both
study groups was close to 75 years, andstudy groups was close to 75 years, and
participants ranged in age from approxi- participants ranged in age from approxi-
mately 66 years old to just under 100 yearsmately 66 years old to just under 100 years
old. To correct for the difference in age old. To correct for the difference in age
distribution between the two groups, thedistribution between the two groups, the
weighting factor described earlier has been weighting factor described earlier has been
applied to all remaining descriptive resultsapplied to all remaining descriptive results
for the comparison group participants.for the comparison group participants.
Table 1 shows that participants fromTable 1 shows that participants from
eithergroup were eithergroupwere
Australian-born. Those in the veteransAustralian-born. Those in the veterans
group were slightly less likely to be marriedgroup were slightly less likely to be married
or in a or in a de factode facto relationship and slightly relationship and slightly
more likely to be widowed, divorced ormore likely to be widowed, divorced or
never married. They were also less likely never married. They were also less likely
to have post-secondary education qualifica-to have post-secondary education qualifica-
tions than members of the comparison tions than members of the comparison
predominantly predominantly
4 76 4 76
AUTHOR’S PROOF AUTHOR’S PROOF

Page 4

PSYCHOLOGICAL HEALTH OF KOREAN WAR VE TER ANS P SYCHOLOGICAL HEALTH OF KOREAN WAR VE TER ANS
group. The differences in overall pattern ofgroup. The differences in overall pattern of
country of birth, current marital status andcountry of birth, current marital status and
highest education level were statisticallyhighest education level were statistically
significant (eachsignificant (each P P550.001).0.001).
KoreanWar deploymentKoreanWar deployment
characteristicscharacteristics
The Korean War deployment characteris- The Korean War deployment characteris-
tics for the participating veterans are showntics for the participating veterans are shown
in Table 2. More than half of the veterans in Table 2. More than half of the veterans
(56%) were aged 21–25 years at the time(56%) were aged 21–25 years at the time
of their first Korean War deployment; theof their first Korean War deployment; the
youngest was 16 and the oldest 47 yearsyoungest was 16 and the oldest 47 years
old.Approximatelyold.Approximately
group (63%) were deployed to Korea group (63%) were deployed to Korea
within 4 years of first joining the Australian within 4 years of first joining the Australian
armed forces. Most were enlisted (74%) armed forces. Most were enlisted (74%)
and more than half (55%) served with theand more than half (55%) served with the
Army. Veterans averaged a total of 285 Army. Veterans averaged a total of 285
days (approximately 9½ months) of de-days (approximately 9½ months) of de-
ployment to Korea, range 1–1188 daysployment to Korea, range 1–1188 days
(not tabulated). Just under 17% of partici-(not tabulated). Just under 17% of partici-
pants were first deployed to Korea duringpants were first deployed to Korea during
the mobile phase of the war prior to 30the mobile phase of the war prior to 30
two-thirds two-thirds ofofthisthis
June 1951. More than 50% were first de-June 1951. More than 50% were first de-
ployed some time during the static phaseployed some time during the static phase
between July 1951 and late July 1953. Anbetween July 1951 and late July 1953. An
additional 30% of participating veteransadditional 30% of participating veterans
were first deployed to Korea after the were first deployed to Korea after the
armistice was signed on 27 July 1953.armistice was signed on 27 July 1953.
The Korean War veterans’ CES scoreThe Korean War veterans’ CES score
categories are shown in Table 3. Approxi-categories are shown in Table 3. Approxi-
mately a fifth (21%) of the veterans re-mately a fifth (21%) of the veterans re-
ported no combat exposure based on the ported no combat exposure based on the
scenarios described in the CES. These veter-scenarios described in the CES. These veter-
ans reported, for example, no casualties inans reported, for example, no casualties in
their unit, never having to fire rounds attheir unit, never having to fire rounds at
the enemy, never seeing others injured bythe enemy, never seeing others injured by
incoming rounds, and never being in dangerincoming rounds, and never being in danger
of being injured or killed in the line of duty.of being injured or killed in the line of duty.
More commonly veterans reported light,More commonly veterans reported light,
light–moderate andlight–moderateand
exposure. A small proportion of the veter- exposure. A small proportion of the veter-
ans (3%) reported heavy combat exposure.ans (3%) reported heavy combat exposure.
Additional descriptive analysis (not tabu-Additional descriptive analysis (not tabu-
lated) indicated that Army veterans werelated) indicated that Army veterans were
more likely to report moderate to heavymore likely to report moderate to heavy
combat exposure than Navy or Air Forcecombat exposure than Navy or Air Force
veterans, as were veterans who servedveterans, as were veterans who served
moderatemoderate combat combat
during the mobile and/or static phases of during the mobile and/or static phases of
the Korean War compared with veteransthe Korean War compared with veterans
who were first deployed after the armistice. who were first deployed after the armistice.
Furthermore, officers were slightly moreFurthermore, officers were slightly more
likely than those of lower rank to reportlikely than those of lower rank to report
no combat. These findings in relation tono combat. These findings in relation to
CES reporting by different veterans’ groupsCES reporting by different veterans’ groups
were broadly consistent with what iswere broadly consistent with what is
known about the Korean War experience. known about the Korean War experience.
Veterans’ reports of being wounded inVeterans’ reports of being wounded in
action during the Korean conflict, and theaction during the Korean conflict, and the
types of evacuation required for their worsttypes of evacuation required for their worst
injury, are also shown in Table 3. The 871injury, are also shown in Table 3. The 871
veterans(14%)who veterans(14%) who
wounded in action, were equally dividedwounded in action, were equally divided
in regard to the four types of evacuation in regard to the four types of evacuation
(items 1–4 in Table 3) reported for their(items 1–4 in Table 3) reported for their
worst injury. Each increase in type of eva-worst injury. Each increase in type of eva-
cuation was considered likely to represent cuation was considered likely to represent
an increase in injury severity. In additionan increase in injury severity. In addition
to their Korean War deployment, 55% ofto their Korean War deployment, 55% of
veteransreportedinvolvementinoneormoreveteransreportedinvolvementinoneormore
othermajor militaryconflicts suchas the Sec-othermajor military conflictssuch asthe Sec-
ond World War, the occupation of Japan byond World War, the occupation of Japan by
theBritishCommonwealthOccupyingForce,theBritishCommonwealthOccupyingForce,
the Malayan emergency, the Borneo/Malay-the Malayan emergency, the Borneo/Malay-
sian confrontation and the Vietnam Warsian confrontation and the Vietnam War
(not tabulated). For 45% of veterans, the (not tabulated). For 45% of veterans, the
Korean War was the only major militaryKorean War was the only major military
conflict in which they participated.conflict in which they participated.
reportedreportedbeing being
Psychological health outcomes Psychological health outcomes
The group mean total scores on each of the The group mean total scores on each of the
HAD scale depression and anxiety sub-HAD scale depression and anxiety sub-
scales are shown in Table 4, and the num- scales are shown in Table 4, and the num-
ber of participants meeting HAD scale ber of participants meeting HAD scale
criteria for depression and/or anxiety (by criteria for depression and/or anxiety (by
reaching the cut-off score of 11 or morereaching the cut-off score of 11 or more
on either sub-scale) are shown in Table 5.on either sub-scale) are shown in Table 5.
Participants from the veterans group re- Participants from the veterans group re-
corded significantly higher mean scores,corded significantly higher mean scores,
representing considerably poorer health, representing considerably poorer health,
on both the depression and anxiety sub-on both the depression and anxiety sub-
scales, and were over five times more likelyscales, and were over five times more likely
than the comparison group to meet HADthan the comparison group to meet HAD
sub-scale criteria for depression or anxiety.sub-scale criteria for depression or anxiety.
Group mean PTSD Checklist scores are alsoGroup mean PTSD Checklist scores are also
shown in Table 4. The veterans group re-shown in Table 4. The veterans group re-
corded significantly higher mean PTSDcorded significantly higher mean PTSD
Checklist scoresthanChecklist scoresthan
group, representing markedly higher symp-group, representing markedly higher symp-
tom reporting in the former group. The tom reporting in the former group. The
numbers of participants meeting criterianumbers of participants meeting criteria
for a PTSD diagnosis, using a PTSD Check-for a PTSD diagnosis, using a PTSD Check-
list score of 45 or more, or a more stringent list score of 45 or more, or a more stringent
score of 50 or more, are shown in Table 5. score of 50 or more, are shown in Table 5.
At both thresholds, those in the veterans At both thresholds, those in the veterans
group were close to six times more likelygroup were close to six times more likely
to meet criteria for a PTSD diagnosis thanto meet criteria for a PTSD diagnosis than
the comparison group participants.the comparison group participants.
thethecomparison comparison
4 7 7 4 7 7
AUTHOR’S PROOFAUTHOR’S PROOF
Table1 Table1
Demographic factorsDemographic factors
KoreanWar veteransKoreanWar veterans
( (n n¼6122)6122)
ComparisongroupComparisongroup
( (n n¼1510)
WeightedWeighted
n n
1510)
n n(%)(%)1 1
(%)(%)1 1
P P2 2
Countryof birthCountryofbirth
AustraliaAustralia
New Zealand New Zealand
UK/Ireland UK/Ireland
OtherOther
Currentmarital statusCurrentmarital status
MarriedMarried4 4
Widowed Widowed
Divorced or separatedDivorced or separated
Single ^ never marriedSingle ^ nevermarried
Highesteducationalqualification Highesteducationalqualification
PrimaryPrimary
Secondarygrades 7^10Secondarygrades 7^10
Secondarygrades11or12 Secondarygrades11or12
CertificateCertificate
DiplomaDiploma
University University
54545454(89.1) (89.1)
(1.2)(1.2)
(8.5)(8.5)
(0.9)(0.9)
1293 1293(85.6)(85.6)
(0.1)(0.1)
(3.8)(3.8)
(10.5) (10.5)
74 74 1 1
57 57
158158
550.0010.0013 3
523 523
6262
43384338
766766
672672
303 303
(70.9) (70.9)
(12.5)(12.5)
(11.0)(11.0)
(4.9)(4.9)
1167 1167
151151
123 123
5454
(77.3)(77.3)
(10.0)(10.0)
(8.1)(8.1)
(3.6) (3.6)
550.001 0.001
13171317
21442144
867867
11801180
322322
245 245
(21.5)(21.5)
(35.0)(35.0)
(14.2)(14.2)
(19.3)(19.3)
(5.3) (5.3)
(4.0)(4.0)
328 328
376376
190190
378378
113 113
111111
(21.7)(21.7)
(24.9)(24.9)
(12.6) (12.6)
(25.1) (25.1)
(7.5)(7.5)
(7.4)(7.4)
550.0010.001
1. Actual1. Actualn n fromwhicheachpercentagescoreisderivedvariesbyup to1%fewerparticipantsdependingonthenumber fromwhicheachpercentagescoreisderivedvariesbyup to1%fewerparticipantsdependingonthenumber
ofrespondents to each question.ofrespondents to each question.
2. Each P valuerefers to the effectof studygroup upon the dependentdemographic measure, after adjustmentfor 2. Each P valuerefers to the effectof studygroup upon the dependentdemographic measure, after adjustmentfor
currentage (65^69,70^74, 75^79, 80^84, 85+ years) andadjustmentfor the other two demographic measuresin the current age (65^69,70^74,75^79, 80^84, 85+ years) andadjustmentfor the other two demographic measuresin the
table, each enteredas categoricalvariables.Whenenteredas adjustmentcovariates, countryofbirthwasrecodedintotable, each enteredas categoricalvariables.Whenenteredas adjustmentcovariates, countryofbirthwasrecodedinto
two categories (Australia; other), marital status wasrecodedinto two categories (married; other) andeducationwastwo categories (Australia; other), marital statuswasrecodedinto two categories (married; other) andeducationwas
recodedinto three categories (grade10 or below; grades11,12 orcertificate; diploma or university).recodedinto three categories (grade10 or below; grades11,12 or certificate; diploma or university).
3. Owing to smallcell sizes, countryofbirth as a dependentmeasurewasrecodedinto three categories (Australia; 3. Owing to smallcell sizes, countryofbirth as a dependentmeasurewasrecodedinto three categories (Australia;
New Zealand/UK/Ireland; other) to obtain this New Zealand/UK/Ireland; other) to obtain this P P value.value.
4. Legallyor4. Legallyordefactodefacto. .
e
f
g
e
f
g
e
d
f
d
g

Page 5

IKIN E T AL IKIN E T AL
Association between psychologicalAssociation between psychological
health and deploymenthealth and deployment
characteristicscharacteristics
Korean War veterans who met criteria for a Korean War veterans who met criteria for a
PTSD diagnosis, as defined by a high PTSDPTSD diagnosis, as defined by a high PTSD
Checklist cut-off score of 50 or more, andChecklist cut-off score of 50 or more, and
veterans who met HAD scale criteria forveterans who met HAD scale criteria for
depression, across subgroups of deploy-depression, across subgroups of deploy-
ment characteristics, are enumerated inment characteristics, are enumerated in
Table 6.Table 6.
Within the veterans group, increasingWithin the veterans group, increasing
odds of meeting criteria for PTSD or de-odds of meeting criteria for PTSD or de-
pression were both associated with increas-pression were both associated with increas-
ing combat exposure, decreasing level ofing combat exposure, decreasing level of
rank, increasing duration of deployment,rank, increasing duration of deployment,
being first deployed before the armistice,being first deployed before the armistice,
and being wounded in action. There was and being wounded in action. There was
also an association between both psycholo-also an association between both psycholo-
gical health outcomes and Service branch,gical health outcomes and Service branch,
with Army veterans demonstrating thewith Army veterans demonstrating the
greatest odds of PTSD or depression,greatest odds of PTSD or depression,
followed by Navy veterans, and with Airfollowed by Navy veterans, and with Air
Force veterans demonstrating the lowestForce veterans demonstrating the lowest
odds. The association between PTSD and odds. The association between PTSD and
increasing level of reported combat expo-increasing level of reported combat expo-
sure was particularly strong, with veteranssure was particularly strong, with veterans
who reported heavy combat almost 15who reported heavy combat almost 15
times more likely to meet criteria for PTSDtimes more likely to meet criteria for PTSD
than veterans who reported no combat. Thethan veterans who reported no combat. The
dose–response slope indicates that the dose–response slope indicates that the
expected increase in the odds of PTSD perexpected increase in the odds of PTSD per
categorical increase in combat exposurecategorical increase in combat exposure
level(e.g.frommoderatetomoderate–heavy)level(e.g.frommoderate tomoderate–heavy)
is 65%. The association between depression is 65%. The association between depression
and combat exposure was also strong, withand combat exposure was also strong, with
a 37% expected increase in the odds of a 37% expected increase in the odds of
depressionpercategorical depressionpercategorical
combat exposure level.combat exposure level.
The other most notable association wasThe other most notable association was
with rank; with enlisted ranks being fourwith rank; with enlisted ranks being four
times more likely – and non-commissionedtimes more likely – and non-commissioned
officers three times more likely – than offi-officers three times more likely – than offi-
cers to meet criteria for PTSD. Enlistedcers to meet criteria for PTSD. Enlisted
ranks and non-commissioned officers wereranks and non-commissioned officers were
also more than twice as likely as officersalso more than twice as likely as officers
to meet criteria for depression. The dose–to meet criteria for depression. The dose–
response slopes indicate a 54% increase inresponse slopes indicate a 54% increase in
the odds of PTSD and a 43% increase in the odds of PTSD and a 43% increase in
the odds of depression per categorical the odds of depression per categorical
decrease in rank.decrease in rank.
The likelihood of PTSD was doubled in The likelihood of PTSD was doubled in
veterans who reported being wounded inveterans who reported being wounded in
action (regardless of evacuation type) com- action (regardless of evacuation type) com-
pared with veterans who did not reportpared with veterans who did not report
being wounded, and almost halved in veter- being wounded, and almost halved in veter-
ans who were first deployed to Korea after ans who were first deployed to Korea after
the armistice compared with veterans who the armistice compared with veterans who
were first deployed during the earlier were first deployed during the earlier
phases of the war. Similar patterns were phases of the war. Similar patterns were
observed for depression, but the associa-observed for depression, but the associa-
tions were not so strong. Increased deploy-tions were not so strong. Increased deploy-
ment duration was associated with anment duration was associated with an
expected 27% increase in the odds of PTSDexpected 27% increase in the odds of PTSD
and a 10% increase in the odds of depres-and a 10% increase in the odds of depres-
sion. Furthermore PTSD – but not depres-sion. Furthermore PTSD – but not depres-
sion – was associated with being younger sion – was associated with being younger
and having fewer years of service experi- and having fewer years of service experi-
ence when deployed. Additional analysisence when deployed. Additional analysis
(not tabulated) indicated that Korean War (not tabulated) indicated that Korean War
veterans who had been deployed to other veterans who had been deployed to other
major conflicts did not have worse psycho- major conflicts did not have worse psycho-
logical health than veterans who had notlogical health than veterans who had not
been deployed to other conflicts.been deployed to other conflicts.
increaseincrease in in
DISCUSSIONDISCUSSION
The results of our study show that approxi- The results of our study show that approxi-
mately five decades after the Korean War,mately five decades after the Korean War,
surviving male Australian veterans are ex-surviving male Australian veterans are ex-
periencing markedly worse psychological periencing markedly worse psychological
health, as indicated by excessive levels of health, as indicated by excessive levels of
anxiety, PTSD and depression, compared anxiety, PTSD and depression, compared
with a group of similarly aged Australianwith a group of similarly aged Australian
men who were residing in Australia at themen who were residing in Australia at the
time of the Korean War. Further, there time of the Korean War. Further, there
are strong observed associations between are strong observed associations between
poor psychological health in veterans and poor psychological health in veterans and
deployment characteristics of the Korean deployment characteristics of the Korean
War, including increasing combat severity,War, including increasing combat severity,
4 784 78
AUTHOR’S PROOFAUTHOR’S PROOF
Table 2 T able 2
KoreanWar veteran deploymentcharacteristicsKoreanWar veteran deploymentcharacteristics
KoreanWar veteransKoreanWar veterans
( (n n¼6122)6122)1 1
Age atfirst KoreanWardeployment, years: mean (s.d.) Age atfirst KoreanWar deployment, years: mean (s.d.)
Age category,Age category,2 2n n (%) (%)
4420 years 20 years
21^25 years21^25years
26^30 years26^30years
5531years31years
Duration ofprevious servicewith Australian armed forces,Duration ofprevious servicewith Australian armed forces,3 3n n (%)
51year1year
1to 1to 552 years2 years
2 to 2 to 554 years 4 years
4 to 4 to 559 years9 years
559 years9 years
ServicebranchServicebranch, , n n (%) (%)
NavyNavy
ArmyArmy
Air ForceAir Force
RankRank, , n n (%)(%)
OfficerOfficer
Non-commissioned officerNon-commissioned officer
EnlistedrankEnlistedrank
ErafirstdeployedEra firstdeployed, , n n (%) (%)
MobilephaseMobilephase
Static phaseStatic phase
After armisticeAfter armistice
Totalduration of deployment,Totalduration of deployment, n n (%) (%)
53 months 3 months
3 to 3 to 556 months6 months
6 to6 to 5512 months12 months
12 to12 to 5518 months18 months
5518 months18 months
Totalduration of deployment, days: mean (s.d.)Totalduration of deployment, days: mean (s.d.)
23.31 23.31 (3.48)(3.48)
1378 1378
34063406
10431043
253253
(22.7)(22.7)
(56.0) (56.0)
(17.2) (17.2)
(4.2)(4.2)
(%)
5
274274
1453 1453
20292029
16081608
600600
(4.6)(4.6)
(24.4)(24.4)
(34.0) (34.0)
(27.0) (27.0)
(10.1)(10.1)
2310 2310
33353335
477477
(37.7)(37.7)
(54.5)(54.5)
(7.8)(7.8)
444 444
11411141
45324532
(7.3)(7.3)
(18.7)(18.7)
(74.1) (74.1)
10181018
32253225
18721872
(16.6)(16.6)
(52.7) (52.7)
(30.6)(30.6)
5
483483
973 973
2663 2663
17041704
282282
284.9284.9
(7.9) (7.9)
(15.9)(15.9)
(43.6) (43.6)
(27.9)(27.9)
(4.6)(4.6)
(139.7) (139.7)
1. Actual1. Actualn n fromwhich eachpercentage or mean scoreis derivedvariesbyup to 3% fewer participants dependingonfromwhich eachpercentage or mean scoreis derivedvariesbyup to 3% fewer participants dependingon
thenumber ofrespondents to each question.thenumber ofrespondents to each question.
2. Age at first KoreanWardeploymentisbasedon self-reporteddate ofbirth and deploymentdatesprovidedby the 2. Age at first KoreanWardeploymentisbased on self-reporteddate ofbirth anddeploymentdatesprovidedby the
Departmentof Veterans’Affairs. Age categorieswere derivedafter rounding ageinyears to thenearestinteger. Departmentof Veterans’Affairs. Age categories were derived after rounding ageinyears to thenearestinteger.
3. Derived from the Departmentof Veterans’Affairs dates of first KoreanWar deployment, and self-reportedyear 3. Derived from the Departmentof Veterans’Affairs dates of first KoreanWar deployment, and self-reportedyear
of firstjoining the Australian armedforces. of firstjoining the Australian armed forces.

Page 6

PSYCHOLOGICAL HEALTH OF KOREAN WAR VE TER ANS P SYCHOLOGICAL HEALTH OF KOREAN WAR VE TER ANS
lower rank, service in the Army and beinglower rank, service in the Army and being
wounded in action, and weaker observedwounded in action, and weaker observed
associations with first deployment duringassociations with first deployment during
the mobile or static phases of the war com-the mobile or static phases of the war com-
pared with after the armistice, increasingpared with after the armistice, increasing
duration of deployment, younger age andduration of deployment, younger age and
decreasing years of previous military servicedecreasing years of previous military service
experience. experience.
Our findings of PTSD prevalences ofOur findings of PTSD prevalences of
26% or 33% in Australian Korean War ve-26% or 33% in Australian Korean War ve-
terans, using two different cut-off scores forterans, using two different cut-off scores for
the PTSD Checklist, are consistent with thethe PTSD Checklist, are consistent with the
majority of recent studies of Korean Warmajority of recent studies of Korean War
and Second World War veterans which re-and Second World War veterans which re-
port PTSD prevalences of 24–32% (Blake port PTSD prevalences of 24–32% (Blake
et alet al, 1990; Engdahl, 1990; Engdahl et al
Stanger, 1997; Schnurr Stanger, 1997; Schnurr et al
& Robbins, 2001; Port& Robbins, 2001; Port et al
tantly, few recent studies have includedtantly, few recent studies have included
comparison groups against which the re-comparison groups against which the re-
sults of the veterans could be directlysults of the veterans could be directly
compared. In our study, the observedcompared. In our study, the observed
prevalence of 5% of comparison group par-prevalence of 5% of comparison group par-
ticipants meeting PTSD Checklist question-ticipants meeting PTSD Checklist question-
nairecriteria forPTSDnairecriteria forPTSD
compared with a 1.2% Australian male compared with a 1.2% Australian male
community prevalence of PTSD previouslycommunity prevalence of PTSD previously
reported using DSM–IV criteria (Creamerreported using DSM–IV criteria (Creamer
et alet al, 2001). This suggests that the PTSD , 2001). This suggests that the PTSD
Checklist questionnaire results may repre- Checklist questionnaire results may repre-
sent an overestimation of the true level of sent an overestimation of the true level of
et al, 1997; Hyer &, 1997; Hyer &
et al, 2000; Hunt, 2000; Hunt
et al, 2001). Impor-, 2001). Impor-
appearsappearshighhigh
PTSD in both study groups. Nevertheless, PTSD in both study groups. Nevertheless,
the magnitude of the difference between the magnitude of the difference between
the veteran and the comparison groups in the veteran and the comparison groups in
this study provides compelling evidence this study provides compelling evidence
that Australian Korean War veterans arethat Australian Korean War veterans are
experiencing markedly higher levels ofexperiencing markedly higher levels of
PTSD than would be expected in Australian PTSD than would be expected in Australian
men of similar age and ethnic background.men of similar age and ethnic background.
As PTSD is an anxiety disorder, it is consis-As PTSD is an anxiety disorder, it is consis-
tent that the study results also show veter-tent that the study results also show veter-
ans to be more likely than the comparisonans to be more likely than the comparison
group to meet HAD criteria for anxiety.group to meet HAD criteria for anxiety.
However, the extent to which anxiety dis-However, the extent to which anxiety dis-
orders other than PTSD affect Korean orders other than PTSD affect Korean
War veteran and comparison group partici-War veteran and comparison group partici-
pants is not evident from the current ana-pants is not evident from the current ana-
lyses. Also using HAD criteria, veteranslyses. Also using HAD criteria, veterans
were shown to be about five times more were shown to be about five times more
likely than the comparison group to experi-likely than the comparison group to experi-
ence depression. As with the PTSD Check-ence depression. As with the PTSD Check-
list questionnaire, the HAD scale resultslist questionnaire, the HAD scale results
may represent a slight overestimation ofmay represent a slight overestimation of
the true prevalence of both anxiety and de- the true prevalence of both anxiety and de-
pressive disorders in both study groups, as pressive disorders in both study groups, as
the observed prevalence of depression in the observed prevalence of depression in
the comparison group is higher than that the comparison group is higher than that
found in a previous Australian community found in a previous Australian community
survey (Australian Bureau ofsurvey (Australian Bureau of Statistics,
1998). Nonetheless, the magnitude 1998). Nonetheless, the magnitude of the
difference between the veterans and thedifference between the veterans and the
comparison group is large. comparison group is large.
Statistics,
of the
Interpretation of the study results inInterpretation of the study results in
regard to psychological health outcomes is regard to psychological health outcomes is
limited by the reliance on self-report psy- limited by the reliance on self-report psy-
chological health instruments. Although chological health instruments. Although
well-validated and psychometrically as- well-validated and psychometrically as-
sessed instruments were used, the addition sessed instruments were used, the addition
of a clinical assessment would have pro- of a clinical assessment would have pro-
vided more objective psychological health vided more objective psychological health
information, and this should be consideredinformation, and this should be considered
in future studies. in future studies.
Previous studies have frequently re- Previous studies have frequently re-
ported increasing severity of combat or ported increasing severity of combat or
war-trauma exposure to be associated with war-trauma exposure to be associated with
PTSD (SpiroPTSD (Spiro et al et al, 1994; Sutker, 1994; Sutker & Allain,
1996; Engdahl1996; Engdahl et alet al, 1997; Hunt &
Robbins, 2001) and our study provides evi-Robbins, 2001) and our study provides evi-
dence of this association persisting stronglydence of this association persisting strongly
some 50 years after the Korean War. The some 50 years after the Korean War. The
conventional interpretation is that the conventional interpretation is that the
stressful exposures are a central risk factor stressful exposures are a central risk factor
for the onset of symptoms (Brewinfor the onset of symptoms (Brewin et al
2000); however, multiple additional factors2000); however, multiple additional factors
are then thought to contribute to symptom are then thought to contribute to symptom
persistence or chronicity (Schnurrpersistence or chronicity (Schnurr et al
2004).2004).
The possibility of recall bias must beThe possibility of recall bias must be
considered in relation to our finding of anconsidered in relation to our finding of an
association between current ill health andassociation between current ill health and
recall of increased combat severity in arecall of increased combat severity in a
war that occurred five decades earlier. It war that occurred five decades earlier. It
may be the case that memory of stressfulmay be the case that memory of stressful
experiences undergoes modification over experiences undergoes modification over
time owing to the presence of psychological time owing to the presence of psychological
or other adverse health symptoms. A long- or other adverse health symptoms. A long-
itudinal study of UK Gulf War veteransitudinal study of UK Gulf War veterans
(Wessely(Wessely et alet al, 2003) found that recall of, 2003) found that recall of
military hazards after conflict was not sta-military hazards after conflict was not sta-
tic and was associated with current self-tic and was associated with current self-
rated perception of health. One possibilityrated perception of health. One possibility
is that individuals who have PTSD, foris that individuals who have PTSD, for
example, remember the events more accu- example, remember the events more accu-
rately than those without the disorder rately than those without the disorder
(McFarlane, 1988). Alternatively, recall of(McFarlane, 1988). Alternatively, recall of
threat or fear may become magnified withthreat or fear may become magnified with
time inindividualstime inindividuals
(Southwick(Southwick et alet al, 1997). We were limited, 1997). We were limited
in our ability to assess the validity of ourin our ability to assess the validity of our
retrospectively collected combat exposure retrospectively collected combat exposure
data; however, we were able to gain somedata; however, we were able to gain some
confidence in the data from our observa-confidence in the data from our observa-
tions that the general patterns of reportedtions that the general patterns of reported
combat severity were in expected direc- combat severity were in expected direc-
tions. For example, participants in thetions. For example, participants in the
veterans group who were first deployed toveterans group who were first deployed to
Korea after the signing of the 1953 armis-Korea after the signing of the 1953 armis-
tice were considerably less likely to report tice were considerably less likely to report
experiencing moderate to heavy combatexperiencing moderate to heavy combat
compared with those who were deployedcompared with those who were deployed
during earlier, active phases of the warduring earlier, active phases of the war
when the conflict was at its height.when the conflict was at its height.
& Allain,
, 1997; Hunt &
et al, ,
et al, ,
withwithsymptomssymptoms
4 794 79
AUTHOR’S PROOF AUTHOR’S PROOF
Table 3Table 3
Combatexposure, whether woundedin action during KoreanWar service, and anyevacuationCombatexposure, whether woundedin action during KoreanWar service, and anyevacuation
KoreanWar veterans KoreanWar veterans
( (n n¼5269)5269)
n n(%)(%)
CES categoryCES category
None None
LightLight
Light^moderateLight^moderate
Moderate Moderate
Moderate^heavyModerate^heavy
HeavyHeavy
Woundedin action ( Woundedin action (n n¼6045)
NoNo
Yes Yes
If yes, evacuated to a:If yes, evacuated to a:
1.Regimental aidpost, first aidpost, sickbayor field ambulance, 1.Regimentalaidpost, first aidpost, sickbayor field ambulance,
and thenreturned to unit/ship/squadron and thenreturned to unit/ship/squadron
2.Local fieldhospitalor hospital ship and thenreturned to unit/2.Local fieldhospital or hospital ship and thenreturned to unit/
ship/squadronship/squadron
3.Hospitalin Japan and thenreturned to unit/ship/squadron 3.Hospitalin Japan and thenreturned to unit/ship/squadron
4.Hospitalin Japan and then to Australia for further medical 4.Hospitalin Japan and then to Australia for furthermedical
attentionattention
11181118
1618 1618
920920
970970
494 494
149149
(21.2)(21.2)
(30.7) (30.7)
(17.5) (17.5)
(18.4)(18.4)
(9.4) (9.4)
(2.8) (2.8)
6045)
51745174
871 871
(85.6) (85.6)
(14.4)(14.4)
241 241(4.0)(4.0)
193193 (3.2) (3.2)
206206
204 204
(3.4) (3.4)
(3.4) (3.4)
CES,Combat Exposure Scale.CES,Combat Exposure Scale.

Page 7

IKIN E T ALIKIN E T AL
Consistent with our findings in relationConsistent with our findings in relation
to rank, lower rank has also previouslyto rank, lower rank has also previously
been shown to be associated with increasedbeen shown to be associated with increased
psychological distress or ill health in Britishpsychological distress or ill health in British
Second World War and Korean WarSecond World War and Korean War
veterans (Hunt & Robbins, 2001), and USveterans (Hunt & Robbins, 2001), and US
Gulf War veterans (IsmailGulf War veterans (Ismail et al
but the reason for these associations is un-but the reason for these associations is un-
clear. In relation to the Korean War experi-clear. In relation to the Korean War experi-
ence, ourdata showedence, ourdata showed
severity, assessed using the Combat Expo-severity, assessed using the Combat Expo-
sure Scale, did not differ markedly accord-sure Scale, did not differ markedly accord-
ing to rank. Also, the association between ing to rank. Also, the association between
rank and ill health in Korean War veteransrank and ill health in Korean War veterans
persisted after statistical adjustment forpersisted after statistical adjustment for
age. Therefore, some other characteristicage. Therefore, some other characteristic
of war deployment related to low rank of war deployment related to low rank
may be contributing to subsequent health. may be contributing to subsequent health.
It is possible that there are rank-related dif-It is possible that there are rank-related dif-
ferences in the experience of combat thatferences in the experience of combat that
the CES is not able to detect. For example, the CES is not able to detect. For example,
our recent research with Australian Navyour recent research with Australian Navy
Gulf War veterans showed that veterans Gulf War veterans showed that veterans
of lower rank reported more dangerousof lower rank reported more dangerous
duties,experienced duties, experienced
associated with an inability to protect selfassociated with an inability to protect self
et al, 2000),, 2000),
thatthat combat combat
moremorehelplessnesshelplessness
or others from harm, and greater fear ofor others from harm, and greater fear of
attack, injury or death, than higher-ranked attack, injury or death, than higher-ranked
veterans (Ikinveterans (Ikin et al et al, 2005)., 2005).
Other military service-related factors –Other military service-related factors –
for example access to strategic information,for example access to strategic information,
knowledge about the combat zone, type ofknowledge about the combat zone, type of
military training, and personnel selectionmilitary training, and personnel selection
criteria such as demonstrated leadership, criteria such as demonstrated leadership,
personality hardiness and coping skills –personality hardiness and coping skills –
may all vary on average across ranks and may all vary on average across ranks and
contribute to psychological vulnerabilitycontribute to psychological vulnerability
or resistance to negative war outcomes.or resistance to negative war outcomes.
Some of the association between rank andSome of the association between rank and
ill health may not be directly related to ill health may not be directly related to
military service or Korean War deploy-military service or Korean War deploy-
ment. Rank could be a proxy for socio-ment. Rank could be a proxy for socio-
economic status (Ismail economic status (Ismail et al
is associated with both psychological and is associated with both psychological and
physical morbidity in civilian populationsphysical morbidity in civilian populations
(Sainsbury & Harris, 2001; Australian In-(Sainsbury & Harris, 2001; Australian In-
stitute of Health and Welfare, 2002). Ourstitute of Health and Welfare, 2002). Our
statistical adjustment for education might statistical adjustment for education might
not have fully controlled for other socio-not have fully controlled for other socio-
economic or related health risk factorseconomic or related health risk factors
which may be associated with rank, such which may be associated with rank, such
as non-military qualifications, income andas non-military qualifications, income and
et al, 2000), which, 2000), which
employment, social support, lifestyle behav-employment, social support, lifestyle behav-
iours or access to medical resources.iours or access to medical resources.
Like rank, the observed association be-Like rank, the observed association be-
tween Army service and psychological illtween Army service and psychological ill
health in Korean War veterans may reflect health in Korean War veterans may reflect
a combination of military service-relateda combination of military service-related
differences between the Army, Navy and differences between the Army, Navy and
Air Force, or non-military differences such Air Force, or non-military differences such
as socio-economic factors or health behav-as socio-economic factors or health behav-
iours. Army service has also been showniours. Army service has also been shown
to be associated with elevated mortalityto be associated with elevated mortality
and cancer incidence in Australian Koreanand cancer incidence in Australian Korean
Warveterans (Australian Warveterans (Australian
Health and Welfare, 2003; Harrex Health and Welfare, 2003; Harrex et al
2003).2003).
Our finding of an association between Our finding of an association between
being wounded in action in Korea and cur- being wounded in action in Korea and cur-
rent psychological disorders in Australian rent psychological disorders in Australian
veterans, is somewhat consistent with simi- veterans, is somewhat consistent with simi-
lar findings in British veterans of thelar findings in British veterans of the
Second World War and Korea (Hunt &Second World War and Korea (Hunt &
Robbins, 2001), the 1991 Gulf War andRobbins, 2001), the 1991 Gulf War and
the 1992–97 Bosnian conflict (Unwinthe 1992–97 Bosnian conflict (Unwin et et
al al, 1999). Our findings, more than 50 years, 1999). Our findings, more than 50 years
after the Korean War ceasefire, suggest thatafter the Korean War ceasefire, suggest that
the recent associations observed in the the recent associations observed in the
InstituteInstitute ofof
et al, ,
4 8 04 8 0
AUTHOR’S PROOF AUTHOR’S PROOF
Table 4 T able 4
Hospital Anxiety and Depression scale and PTSD Checklist scoresHospital Anxiety and Depression scale and PTSD Checklist scores
VeteransgroupVeteransgroup
( (n n¼6122)6122)1 1
Comparisongroup (Comparisongroup (n n¼1510)
WeightedWeighted
1510)1 1
DifferencebetweenunweightedmeansDifferencebetweenunweightedmeans
Multivariable Multivariable
MeanMean (s.d.) (s.d.) MeanMean (s.d.) (s.d.)Age adjustedAge adjusted2 2
adjusted adjusted3 3
95% CI95%CIP P
HAD depression scoreHAD depression score
HAD anxiety scoreHAD anxiety score
PTSD Checklist scorePTSD Checklist score
7.267.26
8.118.11
36.3736.37
(4.39) (4.39)
(4.89)(4.89)
(17.45)(17.45)
4.31 4.31
4.684.68
24.8024.80
(3.24) (3.24)
(3.54)(3.54)
(10.46)(10.46)
2.872.87
3.333.33
11.2211.22
2.772.77
3.21 3.21
10.7710.77
2.52^3.022.52^3.02
2.94^3.492.94^3.49
9.79^11.769.79^11.76
550.0010.001
550.0010.001
550.0010.001
HAD,Hospital Anxiety and Depression; PTSD, post-traumatic stress disorder. HAD,Hospital Anxiety and Depression; PTSD, post-traumatic stress disorder.
1. Actual1. Actualn n fromwhich eachmean and s.d. scoreis derivedvariesbyup to 9% fewer participants dependingon thenumber ofrespondents to each of theinstruments.fromwhich eachmean and s.d. scoreis derivedvariesbyup to 9% fewer participants dependingon thenumber ofrespondents to each of theinstruments.
2. Adjustedforcurrent age (65^69; 70^74; 75^79; 80^84; 85+ years).2. Adjusted for current age (65^69; 70^74; 75^79; 80^84; 85+ years).
3. Adjusted forcurrent age (65^69; 70^74; 75^79; 80^84; 85+ years), education (primary; any secondaryup to grade10; grades11,12 orcertificate; diploma or university), marital 3. Adjustedfor current age (65^69; 70^74; 75^79; 80^84; 85+ years), education (primary; any secondaryup to grade10; grades11,12 or certificate; diploma or university), marital
status (married orstatus (married ordefactodefacto; widowed; divorced or separated; single, never married) andcountryofbirth (Australia; other).; widowed; divorcedor separated; single, nevermarried) andcountryofbirth (Australia; other).
Table 5T able 5
Participantsmeeting scale criteria fordepression and/or anxiety andpost-traumatic stress disorder Participantsmeeting scale criteria for depression and/or anxiety andpost-traumatic stress disorder
VeteransgroupVeteransgroup
( (n n¼6122)6122)1 1
Comparisongroup (Comparisongroup (n n¼1510)
WeightedWeighted
1510)1 1
OR OR
Multivariable Multivariable
n n (%) (%)n n (%)(%) Age adjusted Age adjusted2 2
adjustedadjusted3 3
95% CI 95%CIP P
HAD scaleHAD scale
DepressionDepression
AnxietyAnxiety
PTSD Checklist PTSD Checklist
Cut-off Cut-off 5
Cut-offCut-off 5
13691369
18821882
(23.5)(23.5)
(31.3)(31.3)
64 64
100100
(4.5)(4.5)
(6.7)(6.7)
5.715.71
5.875.87
5.455.45
5.74 5.74
4.26^6.974.26^6.97
4.65^7.09 4.65^7.09
550.0010.001
550.001 0.001
545 45
550 50
18071807
1426 1426
(32.5)(32.5)
(25.6) (25.6)
99 99
64 64
(7.1)(7.1)
(4.6)(4.6)
6.16 6.16
6.826.82
5.89 5.89
6.636.63
4.74^7.32 4.74^7.32
5.09^8.63 5.09^8.63
550.001 0.001
550.001 0.001
HAD,Hospital Anxiety and Depression; PTSD, post-traumatic stress disorder. HAD,Hospital Anxiety and Depression; PTSD, post-traumatic stress disorder.
1. Actual 1. Actualn n fromwhich eachpercentage scoreis derivedvariesbyup to 9% fewer participants dependingon thenumber ofrespondents to each of theinstruments.fromwhich eachpercentage scoreis derivedvariesbyup to 9% fewer participants dependingon thenumber ofrespondents to each of theinstruments.
2. Adjustedforcurrent age (65^69; 70^74; 75^79; 80^84; 85+ years).2. Adjusted for current age (65^69; 70^74; 75^79; 80^84; 85+ years).
3. Adjusted forcurrent age (65^69; 70^74; 75^79; 80^84; 85+ years), education (primary; any secondaryup to grade10; grades11,12 orcertificate; diploma or university), marital 3. Adjustedfor current age (65^69; 70^74; 75^79; 80^84; 85+ years), education (primary; any secondaryup to grade10; grades11,12 or certificate; diploma or university), marital
status (married orstatus (married ordefactodefacto; widowed; divorced or separated; single, never married) andcountryofbirth (Australia; other). ; widowed; divorcedor separated; single, nevermarried) andcountryofbirth (Australia; other).

Page 8

PSYCHOLOGICAL HEALTH OF KOREAN WAR VE TER ANS P SYCHOLOGICAL HEALTH OF KOREAN WAR VE TER ANS
4 814 81
AUTHOR’S PROOFAUTHOR’S PROOF
Table 6Table 6
Veteransmeeting scale criteria fordepression andpost-traumatic stress disorder bydeploymentcharacteristics Veteransmeeting scale criteria for depression andpost-traumatic stress disorder bydeploymentcharacteristics
Veteransmeeting HAD scale criteria for depression Veteransmeeting HAD scale criteria fordepressionVeteransmeeting PTSD Checklistcriteria for PTSD at50+ cut-off scoreVeteransmeeting PTSD Checklistcriteria for PTSD at50+ cut-off score
KoreanWar deploymentKoreanWar deployment
characteristiccharacteristic
n n (%) (%)Adjusted oddsAdjusted odds
ratio (95% CI)ratio (95% CI)1 1
P Pn n (%) (%)Adjusted odds Adjusted odds
ratio (95% CI) ratio (95% CI)1 1
P P
Age atdeploymentAge atdeployment
420 years 20 years
21^25years21^25 years
26^30years 26^30 years
531years 31years
Dose^responseDose^response3 3
Rank Rank
Officer Officer
NCONCO
Enlisted Enlisted
Dose^responseDose^response3 3
ServicebranchServicebranch
Navy Navy
ArmyArmy
Air ForceAir Force
Duration of previous Australian armed forces service Duration ofprevious Australian armed forces service
51year1year
1to1to 554 years4 years
554 years 4 years
Dose^responseDose^response3 3
Totalduration of deploymentTotalduration of deployment
56 months6 months
6 to6 to 5512 months12 months
5512 months12 months
Dose^responseDose^response3 3
Erafirstdeployed Erafirstdeployed
MobilephaseMobilephase
Static phaseStatic phase
After armistice After armistice
Woundedin action Woundedin action
No No
YesYes
Evacuation type1or 2Evacuation type1or 2
Evacuation type 3 or 4Evacuation type3 or 4
Dose^responseDose^response3 3
CES score CES score
No combatNo combat
Light Light
Light^moderate Light^moderate
ModerateModerate
Moderate^heavyModerate^heavy
HeavyHeavy
Dose^responseDose^response3 3
4
358 (27.3)358 (27.3)
755 (23.2)755 (23.2)
194(19.5) 194 (19.5)
48 (20.4)48 (20.4)
1.001.00
0.85(0.71^1.0 0.85 (0.71^1.01) 1)
0.79(0.60^1.05)0.79 (0.60^1.05)
0.72 (0.40^1.30)0.72 (0.40^1.30)
0.88 (0.77^1.00)0.88 (0.77^1.00)
406 (31.9) 406 (31.9)
808 (26.1)808 (26.1)
168 (17.9)168 (17.9)
28 (12.8)28 (12.8)
1.001.00
0.78 (0.66^0.92)0.78 (0.66^0.92)
0.56(0.42^0.75)0.56(0.42^0.75)
0.51 (0.27^0.98)0.51 (0.27^0.98)
0.77 (0.67^0.87)0.77 (0.67^0.87)
0.2490.2492 2
550.000.001 12 2
5
0.058 0.058
550.00 0.001 1
44 (10.0)44 (10.0)
225(20.5)225(20.5)
1100 (25.6) 1100 (25.6)
1.001.00
2.13 (1.45^3.13)2.13 (1.45^3.13)
2.69 (1.84^3.92) 2.69 (1.84^3.92)
1.43(1.25^1.65)1.43(1.25^1.65)
28 (6.7)28 (6.7)
227(21.5) 227(21.5)
1168 (28.6) 1168 (28.6)
1.00 1.00
3.36(2.15^5.25)3.36 (2.15^5.25)
4.19 (2.71^6.48)4.19 (2.71^6.48)
1.54 (1.34^1.78)1.54 (1.34^1.78)
550.0010.0012 2
550.0010.0012 2
550.0010.001
550.0010.001
457 (20.7) 457 (20.7)
832 (26.3)832 (26.3)
80 (17.2)80 (17.2)
1.001.00
1.38(1.21^1.58)1.38 (1.21^1.58)
0.82 (0.62^1.07)0.82(0.62^1.07)
470 (22.2)470 (22.2)
892 (29.8) 892 (29.8)
64 (14.3)64 (14.3)
1.001.00
1.51 (1.32^1.73)1.51 (1.32^1.73)
0.62 (0.47^0.83)0.62 (0.47^0.83)
550.0010.0012 2
550.001 0.0012 2
5
67 (26.2)67 (26.2)
818 (24.6) 818 (24.6)
435 (20.6)435 (20.6)
1.001.00
0.87 (0.65^1.17)0.87(0.65^1.17)
0.77 (0.56^1.05)0.77 (0.56^1.05)
0.88 (0.76^1.0 0.88 (0.76^1.01) 1)
69 (27.1) 69 (27.1)
916 (28.7) 916 (28.7)
406 (20.4)406 (20.4)
1.001.00
1.03 (0.77^1.39)1.03 (0.77^1.39)
0.80 (0.58^1.10.80 (0.58^1.10) 0)
0.84 (0.74^0.96)0.84 (0.74^0.96)
0.172 0.1722 2
0.00.013132 2
0.0610.0610.0120.012
5
303 (21.9) 303 (21.9)
569 (22.4)569 (22.4)
491 (25.9)491 (25.9)
1.001.00
0.95(0.81^1.12)0.95 (0.81^1.12)
1.18 (0.996^1.40)1.18 (0.996^1.40)
1.1 1.10 (1.01^1.20)0 (1.01^1.20)
281 (21.2)281 (21.2)
585(24.2)585(24.2)
558 (30.9)558 (30.9)
1.001.00
1.08 (0.91^1.27)1.08 (0.91^1.27)
1.55 (1.31^1.83)1.55 (1.31^1.83)
1.27(1.16^1.38)1.27 (1.16^1.38)
0.0100.0102 2
550.0010.0012 2
0.0270.027
550.000.001 1
224 (25.4)224 (25.4)
758 (24.6) 758 (24.6)
363 (20.3)363 (20.3)
1.001.00
0.92 (0.77^1.1 0.92 (0.77^1.10) 0)
0.68 (0.55^0.83)0.68 (0.55^0.83)
236 (25.9)236(25.9)
829(28.3) 829 (28.3)
359 (20.9)359 (20.9)
1.001.00
1.0 1.01 (0.85^1.21)1 (0.85^1.21)
0.60 (0.49^0.74)0.60 (0.49^0.74)
550.0010.0012 2
550.0010.0012 2
1077 (21.8)1077 (21.8)1.001.001081 (22.8) 1081 (22.8)1.001.00
550.0010.0012 2
135 (32.8) 135 (32.8)
130(33.5)130 (33.5)
1.57 (1.25^1.97)1.57 (1.25^1.97)
1.63 (1.29^2.07)1.63 (1.29^2.07)
1.32 (1.19^1.48)1.32 (1.19^1.48)
550.0010.0012 2
174 (44.1) 174 (44.1)
144 (39.7)144 (39.7)
2.35 (1.88^2.93)2.35 (1.88^2.93)
1.99 (1.57^2.52)1.99 (1.57^2.52)
1.54 (1.38^1.72)1.54 (1.38^1.72)
550.00 0.001 1
550.0010.001
141 (13.1)141 (13.1)
296 (18.9) 296(18.9)
212 (24.0)212 (24.0)
251 (27.2)251 (27.2)
167 (35.5)167 (35.5)
69 (47.3)69 (47.3)
1.001.00
1.52 (1.22^1.90)1.52 (1.22^1.90)
2.03 (1.59^2.58)2.03 (1.59^2.58)
2.43(1.91^3.1 2.43(1.91^3.10) 0)
3.55 (2.69^4.68)3.55 (2.69^4.68)
5.96 (4.04^8.80)5.96 (4.04^8.80)
1.37 (1.29^1.44)1.37 (1.29^1.44)
114 (11.0) 114 (11.0)
286 (18.8)286 (18.8)
217 (25.5)217 (25.5)
320 (35.8)320 (35.8)
217 (46.5) 217 (46.5)
78 (60.9)78 (60.9)
1.001.00
1.84 (1.45^2.34) 1.84 (1.45^2.34)
2.91 (2.25^3.76) 2.91 (2.25^3.76)
4.76 (3.69^6.13)4.76 (3.69^6.13)
7.39 (5.54^9.86)7.39 (5.54^9.86)
14.64 (9.52^22.50)14.64 (9.52^22.50)
1.65(1.56^1.75) 1.65(1.56^1.75)
550.0010.0012 2
550.000.001 12 2
550.00 0.001 1
550.00 0.001 1
CES,Combat Exposure Scale; HAD,Hospital Anxiety and Depression scale; NCO, non-commissioned officer; PTSD, post-traumatic stress disorder.CES,Combat Exposure Scale; HAD,Hospital Anxiety and Depression scale; NCO, non-commissionedofficer; PTSD, post-traumatic stress disorder.
1. Oddsratios andtheir associatedconfidenceintervals and1. Oddsratiosandtheir associatedconfidenceintervals and P P values,for alldependentmeasuresexceptwoundedinactionandCESscore,areadjustedfor age(65^69;70^74;75^79; values,for alldependentmeasuresexceptwoundedinactionandCESscore,areadjustedfor age(65^69;70^74;75^79;
80^84; 85+ years), education (primary; any secondaryup to grade10; grades11,12 orcertificate; diploma or university), marital status (married; widowed; divorced or separated;80^84; 85+ years), education (primary; any secondaryup to grade10; grades11,12 or certificate; diploma or university), marital status (married; widowed; divorced or separated;
single, never married) andcountryofbirth (Australia; other).Results for the dependentmeasureswoundedin action and CES scoreinclude additionaladjustmentforrankin Korea single, nevermarried) andcountryofbirth (Australia; other).Results for the dependentmeasures woundedin action and CES scoreinclude additionaladjustmentfor rankin Korea
(officer; NCO; enlisted) and servicebranch (Navy, Army, Air Force). (officer; NCO; enlisted) and servicebranch (Navy, Army, Air Force).
2. Thesevalues assess whether any adjustedoddsratios within each exposurevariable differ fromunity. 2. Thesevalues assess whether any adjusted oddsratios within each exposurevariable differ fromunity.
3. Dose^responseper categoricalchangein this deploymentcharacteristic.3. Dose^responsepercategoricalchangein this deploymentcharacteristic.
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g
e
f
g

Page 9

IKIN E T ALIKIN E T AL
younger Bosnian and Gulf War veterans younger Bosnian and Gulf War veterans
(Unwin (Unwin et alet al, 1999) could persist long into , 1999) could persist long into
the future. An association between in-the future. An association between in-
creased deployment duration and increased creased deployment duration and increased
post-traumaticstresspost-traumaticstress
previously been observed in veterans ofpreviously been observed in veterans of
the Vietnam War (Vincentthe Vietnam War (Vincent et al
and Bosnia (Adler and Bosnia (Adler et al et al, 2005). Our findings
again suggest that this effect can persist for again suggest that this effect can persist for
a considerable time after deployment.a considerable time after deployment.
The study results suggest a complexThe study results suggest a complex
interrelationship between characteristics ofinterrelationship between characteristics of
war service and subsequent long-term psy- war service and subsequent long-term psy-
chological ill health. Combat severity andchological ill health. Combat severity and
duration, war-related injury, inexperience,duration, war-related injury, inexperience,
lack of seniority, and youthfulness all con-lack of seniority, and youthfulness all con-
tribute to long-term psychological morbid-tribute to long-term psychological morbid-
ity. There may be other military and non-ity. There may be other military and non-
military characteristics, such as a malevo- military characteristics, such as a malevo-
lent and/or toxic combat environment,lent and/or toxic combat environment,
socio-economicdisadvantage, socio-economicdisadvantage,
personality traits and levels of social sup-personality traits and levels of social sup-
port, that could have also contributed toport, that could have also contributed to
veterans’ vulnerability to illness and theveterans’ vulnerability to illness and the
persistence of symptoms over time, but in-persistence of symptoms over time, but in-
vestigations of these were outside the scopevestigations of these were outside the scope
of our study. of our study.
Importantly, although past exposuresImportantly, although past exposures
and lifestyle factors cannot be changed,and lifestyle factors cannot be changed,
evidence-based treatments for PTSD, anxi- evidence-based treatments for PTSD, anxi-
ety and depression are available (e.g.ety and depression are available (e.g.
National Institute for Health and Clinical National Institute for Health and Clinical
Excellence, 2006) and these may be effec- Excellence, 2006) and these may be effec-
tive in reducing the considerable psycholo-tive in reducing the considerable psycholo-
gical ill health experienced by Koreangical ill health experienced by Korean
War veterans in their remaining years. InWar veterans in their remaining years. In
this regard, the results of our study shouldthis regard, the results of our study should
be useful in identifying the most appropri- be useful in identifying the most appropri-
ate health interventions and levels of service ate health interventions and levels of service
provision required by surviving Koreanprovision required by surviving Korean
War veterans. The results of our studyWar veterans. The results of our study
could be viewed as providing a possiblecould be viewed as providing a possible
‘snapshot’ of the future health concerns‘snapshot’ of the future health concerns
faced by younger veterans of more recentfaced by younger veterans of more recent
conflicts. Indeed, the results of the studyconflicts. Indeed, the results of the study
could be useful in identifying those veter-could be useful in identifying those veter-
ans of more recent conflicts who may beans of more recent conflicts who may be
at greatest risk of adverse psychologicalat greatest risk of adverse psychological
health outcomes, and in developing ap-health outcomes, and in developing ap-
propriate improved strategies to preventpropriate improved strategies to prevent
or reduce long-term psychological morbid-or reduce long-term psychological morbid-
ity. Long-term follow-up of these veteranity. Long-term follow-up of these veteran
groups will be important to assess the groups will be important to assess the
effectiveness of effectiveness of any new treatments andany new treatments and
other interventions.other interventions.
symptomssymptoms hashas
et al, 1994), 1994)
, 2005). Our findings
individual individual
ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS
We are grateful to the following groups and individ-We are grateful to the following groups and individ-
uals: Professors Priscilla Kincaid Smith (Chair), Johnuals: Professors Priscilla Kincaid Smith (Chair), John
McNeil and John Zalcberg from the Scientific Advi- McNeil and John Zalcberg from the Scientific Advi-
sory Committee; Colonel Alan McDonald (Retd), sory Committee; Colonel Alan McDonald (Retd),
Rear Admiral Simon Harrington, Major General Rear Admiral Simon Harrington, Major General
Paul Stevens and other members ofthe ConsultativePaul Stevens and other members ofthe Consultative
Forum representing the veteran and service com-Forum representing the veteran and service com-
munity; Mr Denis Murphy, Ms Helen Westbury, Msmunity; Mr Denis Murphy, Ms Helen Westbury, Ms
Di Sumerhayes and other project staff at theDi Sumerhayes and other project staff at the
Australian Government Department of Veterans’Australian Government Department of Veterans’
Affairs; consultants Dr Philip Boorman and MrAffairs; consultants Dr Philip Boorman and Mr
Robert van der Hoek; statistical advisor AssociateRobert van der Hoek; statistical advisor Associate
Professor Andrew Forbes and other Monash Uni-Professor Andrew Forbes and other Monash Uni-
versity project staff Mr Anthony Del Monaco, Msversity project staff Mr Anthony Del Monaco, Ms
Elsa Barton, Ms Christina Dimitriadis, Ms Anna Elsa Barton, Ms Christina Dimitriadis, Ms Anna
Davidson and Ms Kate Davidson; and the KoreanDavidson and Ms Kate Davidson; and the Korean
War veterans andcomparisongroupwhofreelygave War veterans andcomparisongroupwhofreelygave
their time to participate in this study. Financialtheir time to participate in this study. Financial
support for this research was received from thesupport for this research was received from the
Australian Government Department of Veterans’ Australian Government Department of Veterans’
Affairs andthe National Health and Medical ResearchAffairs andthe National Health and Medical Research
Council.Council.
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4 824 82
AUTHOR’S PROOFAUTHOR’S PROOF
JILLIAN F.IKINJILLIANF.IKIN,BA,
Environmental Health,Departmentof Epidemiology and Preventive Medicine,Monash University,Melbourne,Environmental Health,Department of Epidemiology and Preventive Medicine,Monash University,Melbourne,
Victoria;Victoria;KEITH W . A.HORSLEYKEITH W . A.HORSLEY,MPA, ,MPA,EILEENJ.WILSONEILEENJ.WILSON,PhD, Australian Government Department of
Veterans’Affairs,Canberra;Veterans’Affairs,Canberra; MICHAELR.MOOREMICHAELR.MOORE,DSc,National Research Centre for Environmental,DSc,National Research Centre for Environmental
Toxicology,University of Queensland,Brisbane;Toxicology,University of Queensland,Brisbane; PAUL JELFSPAUL JELFS,PhD,Cancer Institute New SouthWales,Eveleigh,
New SouthWales;New SouthWales; WARRENK.HARREXWARRENK.HARREX,MSc(OccMed), Australian Government Department of Veterans’ ,MSc(OccMed), Australian Government Departmentof Veterans’
Affairs,Canberra;Affairs,Canberra; SCOTT HENDERSONSCOTT HENDERSON,DSc,John Curtin School of Medical Research, Australian National,DSc,John Curtin School of Medical Research, Australian National
University,Canberra, AustraliaUniversity,Canberra, Australia
,BA,MALCOLMR.SIM MALCOLMR. SIM,PhD,,PhD,DEANP.MCKENZIEDEANP.MCKENZIE,BA,Centre for Occupational and ,BA,Centre for Occupational and
,PhD, Australian Government Departmentof
,PhD,Cancer Institute New SouthWales,Eveleigh,
Correspondence:Jillian Ikin,Monash University,Departmentof Epidemiologyand Preventive Medicine,Correspondence:Jillian Ikin,Monash University,Departmentof Epidemiologyand Preventive Medicine,
The Alfred,Commercial Road,Melbourne,VIC 3001,Australia.Email: jill.ikinThe Alfred,Commercial Road,Melbourne,VIC 3001,Australia.Email: jill.ikin@ @med.monash.edu.aumed.monash.edu.au
(First received 25 April 2006, finalrevision 26 July 2006, accepted 27 October 2006)(First received 25 April 2006, finalrevision 26 July 2006, accepted 27 October 2006)

Page 10

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